Bilateral internal mammary angiography through a right radial approach: a case report

This case report demonstrates that bilateral internal mammary angiography through a single right-radial approach is feasible and convenient. It avoids double-brachial or radial artery puncture, is adapted to the variable characteristics of right internal mammary artery origin, and may be considered when the femoral approach is contraindicated.

Recanalization of chronic coronary occlusions using a new hydrophilic guidewire

Chronic total occlusion remains a relative contraindication and the main cause of failure of coronary angioplasty. Previously available hydrophilic guidewires had numerous limitations. The Crosswire is a new 0.014" hydrophilic nitinol guidewire which can be accommodated by very-low-profile balloon catheters and has a shapeable and highly radiopaque platinum-iridium coiled tip. This guidewire was used in 55 patients with 56 chronic coronary occlusions in which recanalization by conventional guidewires had failed. Clinical success was 79%. Coronary perforation occurred in two cases, one of them requiring pericardiocentesis for tamponade. These results illustrate the usefulness of this new guidewire in the treatment of chronic total occlusions.

Preliminary experience with the NIR coronary stent

We prospectively studied 223 patients (288 lesions) who underwent elective or bail out implantation of 309 NIR stents (Scimed, Boston Scientific Corporation, Galway, Ireland). Most lesions (68.4%) had unfavorable characteristics (type B2 or C). Primary success in stent deployment was achieved in 305 (98.6%). There was no Q-wave myocardial infarction. Emergency coronary artery bypass grafting (CABG) was required in 1 patient and 1 death occurred. Subacute thrombosis rate was 0.4%. Reference diameter was 2.65+/-0.67 mm. Minimum luminal diameter (MLD) increased from 0.62+/-0.45 to 2.69+/-0.57 mm and diameter stenosis decreased from 78.3+/-13.4% to 12.7+/-5.9%. Clinical follow-up was performed in the first 135 patients for 5.3+/-1.6 months and repeat angiography was undertaken in 35 (16%) with recurrence of symptoms at 4.6+/-1.3 months. Clinical restenosis rate was 9.6%. We conclude that the NIR coronary stent exhibits favorable performance characteristics and appears to be safe and efficacious in the treatment of coronary lesions even in the presence of high-risk characteristics.

Silent myocardial ischaemia and left ventricle hypertrophy in diabetic patients

The purpose of this study was to evaluate the ability of three noninvasive techniques to detect silent myocardial ischaemia and analyse the factors associated with this condition, particularly left ventricular hypertrophy, in diabetic patients. An ECG stress test, a thallium-201 myocardial scintigraphy with dipyridamole intravenous infusion, ambulatory 48 h ECG monitoring and an echocardiographic study were performed in 92 diabetic patients without cardiac symptoms but with > or = 2 additional cardiovascular risk factors. At least one of these tests was positive in 28 patients (30.4%), suggesting silent myocardial ischaemia. Twenty-four of these patients had a coronary angiography which showed significant coronary stenosis in only 9 cases. An accurate echocardiographic tracing was obtained in 79 patients, particularly in 7 of the 9 with coronary stenosis. Left ventricular hypertrophy was detected in 34 patients, 6 of whom had coronary stenosis. In patients with left ventricular hypertrophy, the positive predictive values of myocardial scintigraphy and the ECG stress test were respectively 50% and 100%, as compared to only 33% and 11% in those without hypertrophy. In summary, coronary stenoses were found in < 10% of asymptomatic diabetic patients with > or = 2 cardiovascular risk factors, but more frequently in individuals with left ventricular hypertrophy. Thus, silent myocardial ischaemia should be searched for first in diabetic patients with hypertrophy, for which the stress test was the most accurate detection method in this study.

Multiple stenting in acute myocardial infarction with double vessel occlusion, complicated with cardiogenic shock

Stenting of the infarct-related artery during the acute phase of myocardial infarction is a controversial issue. We report a case of primary multiple stent implantation in 2 vessels in a patient with AMI, double vessel total occlusion and cardiogenic shock. No intracoronary thrombotic therapy was given. Stenting provides an optimal angiographic result which may decrease the need for repeat interventions. Primary stenting in AMI deserves further investigation.

Quantitative comparison of prone and supine myocardial SPECT MIBI images

The myocardial count distribution and the stress/rest ratio distribution were compared between prone and supine Tc-99m MIBI myocardial SPECT acquisitions. Ninety-nine male patients with a low stress supine inferior wall count underwent stress and rest acquisitions in the supine and prone positions successively. For each study, values depicting the inferior, anterior, septal, and lateral wall counts were extracted from a medioventricular normalized circumferential profile and underwent a statistical analysis (Student's paired t-test). On prone imaging, when compared to supine imaging, counts showed a highly significant mean relative increase of 11% +/- 1% in the inferior wall and of 7% +/- 1% in the septum. Conversely, these counts showed a significant mean relative decrease of 4% +/- 1% in the anterior wall and of 3% +/- 1% in the lateral wall. Moreover, the inferior wall stress/rest ratio showed a highly significant mean relative increase (6% +/- 2%). The prone position is probably preferable for interpreting the inferior wall and septum, where relative counts are enhanced, as with TI-201, and because the inferior stress-rest discrepancies are reduced in that position. But the anterior and lateral wall information is impaired in the prone position. The authors suggest, in case of a low stress supine inferior count, the combination of both positions, which is feasible with Tc-99m MIBI, in order to prevent a misleading interpretation.

Visualization of myocardial infarction six hours after injection of 111 In-antimyosin antibodies using an image subtraction technique

111 In-antimyosin antibodies are capable of visualizing acute myocardial infarction (MI). Because of slow blood clearance, images are usually recorded 24 or 48 h postinjection. This pilot study was aimed at validating a blood pool subtraction technique, which makes it possible to visualize MI 6 h postinjection. Twenty-five patients with proven MI (16 anterior, 9 inferior) were imaged 10 minutes, 6 and 24 h after an injection of 110 MBq 111 In-labelled antimyosin antibodies, with a mean delay of two weeks after infarction. Three planar views were obtained each time. Using software which performs geometric registration, grey level normalization and subtraction of images, the blood pool image (obtained 10 minutes postinjection) was subtracted from the 6 hour image. The resulting image was the blood pool corrected 6 h image. The 24 h images and the blood pool corrected 6 h images were interpreted blindly and the number of correct, incorrect and indeterminate MI localizations were tabulated. The number of correct localizations was 19/25 for the standard 24 h images and 22/25 for the blood pool corrected 6 h images. With this blood pool subtraction method it was possible to visualize MI 6 h postinjection. Theoretically, this method could be applied six hours after myocardial infarction.

Shape preserving three-dimensional display of myocardial scintigraphic data

A three-dimensional display has been developed which is specifically suited to the visualization of myocardial single photon emission tomographic (SPET) data. A set of radial maxima voxels, representative of the whole left ventricle uptake and shape is first extracted by cylindrical and spherical sampling of the short axis slices. A three-dimensional representation of these voxels is then obtained, with hues depicting the uptake amount and shades (i.e. intensity and saturation) depicting the shape. This technique is suitable for 201Tl and 99TCm-hexakis-2-methoxyisobutyl isonitrile (99TCm-sestamibi) myocardial images. It is proposed as an aid to interpreting myocardial SPET as it enables the physician to distinguish simultaneously the actual shape, the extent and the severity of perfusion defects on a single frame.

[Value of transesophageal echography in the detection of left intraventricular masses. Apropos of a case of apical thrombus]

The authors report a case of left intraventricular thrombus investigated by two-dimensional transesophageal echocardiography (TEE). Three longitudinal views obtained by rotation, left lateral inclination and by advancing the probe, enabled the precise evaluation of a mass situated at the apex of the left ventricle, together with ventricular morphology and kinetics. Two-dimensional TEE is electively indicated for confirmation of the diagnosis of left intraventricular apical masses, in particular in hypoechogenic patients and to guide possible surgery. The two-plane probe provides a certain number of sections which remain relatively limited but this problem is resolved with the development of multidimensional probes.

What factors determine indium-111 antimyosin monoclonal antibody uptake in patients with myocardial infarction?

The intensity of indium-111 antimyosin monoclonal antibody uptake for visualization of myocardial infarction seems partially dependent on the state of the infarct related coronary artery. The aim of this study is to determine the factors which could account for the monoclonal antibody uptake variability. For this purpose, we investigated 27 patients (mean age 52.7 +/- 9.6 years) with a first proven myocardial infarction, by monoclonal antibody scintigraphy and coronary arteriography within the same period of time (7.12 +/- 6 days). The monoclonal antibody uptake was quantified by the heart/lung ratio on images recorded 24 h after injection. The infarct size was quantitatively estimated on wall motion analysis of twelve segments in 30 degree right anterior-oblique view with a radial method. The infarct related coronary artery state was assessed by the Thrombosis in Myocardial Infarction grade and the functional characteristics of collateral vessels by Rentrop's classification. These three variables as well as location of myocardial infarction, left ventricular ejection fraction, administration of a thrombolytic therapy, delay between myocardial infarction and monoclonal antibody scintigraphy were studied using non parametric test, or by linear regression method in order to determine whether these factors would influence the heart/lung ratio. None of these parameters except infarct size was related to heart/lung ratio. Consequently, monoclonal antibody uptake is only dependent on the extent of infarcted myocardium and the intensity of uptake cannot predict the patency of an infarct related coronary artery.

[Chronic constrictive pericarditis after heart surgery. Apropos of a case]

A case of pericarditis in a 52-year old patient following aorto-coronary shunt surgery is reported which gradually developed into chronic constrictive pericarditis. In this context, the diagnostic criteria of chronic constrictive pericarditis are recalled. The clinical criteria show little specificity; Doppler ultrasound provides good diagnostic information; CT scans and nuclear magnetic imaging can confirm the diagnostic. The post-heart surgery etiology has increased in recent years. The only real treatment is surgical and consists of pericardial decortication.

A multivariate analysis of the diagnostic values of clinical examination, exercise testing and exercise radionuclide angiography in coronary artery disease

Data of clinical examination, exercise testing and exercise radionuclide angiography in 102 patients referred for assessment of chest pain was included in a logistic regression to optimize the diagnosis of coronary artery disease with coronary arteriography as the reference investigation. None of the patients had other cardiac problems or previous myocardial infarction. In the absence of symptoms, exercise testing was continued until at least 80% of the theoretical maximal heart rate was attained. Each patient was characterized by the value of the logistic function or probability of coronary artery disease. A threshold value corresponding to 80% sensitivity of ROC graphs was determined. The significant variables were: a clinical variable--the type of chest pain as assessed by the clinical history; two radionuclide angiographic variables--the ejection fraction at peak effort and the corrected variation of ejection fraction between rest and stress, that is not taking into account possible decreases at the last increment of exercise. Coronary patients can be identified with an 80% sensitivity and 77% specificity on these criteria. This specificity is greater than that obtained by clinical examination and exercise testing alone (65%). Exercise radionuclide angiography may therefore reduce the number of unnecessary coronary arteriographies.

Visualization of myocardial infarction 6 h after injection of 111In-antimyosin antibodies using a blood pool subtraction technique

111In-antimyosin antibodies are capable of visualizing myocardial infarction (MI). Because of slow blood clearance, images are usually recorded 24 or 48 h postinjection. In this pilot study, a blood pool subtraction technique, which makes it possible to visualize MI 6 h postinjection, is validated. Twenty-five patients with proven MI (16 anterior, 9 inferior) were imaged a few minutes, 6 and 24 h after an injection of 111 MBq 111In-labelled antimyosin antibodies. Three planar views are obtained each time. Using software which performs the geometric registration, the grey level normalization and the subtraction of images, the blood pool image (obtained a few minutes postinjection) is subtracted from the 6 h image. The resulting image is the blood pool corrected 6 h image. The 24 h images and the blood pool corrected 6 h images were interpreted blindly and the number of correct, incorrect and impossible MI localizations was counted. The number of correct localizations is 19/25 for the standard 24 h images and 22/25 for the blood pool corrected 6 h images. Then, with this blood pool subtraction method, it is possible to visualize MI 6 h postinjection. This has to be taken into account when discussing the role of antimyosin scintigraphy in the management of patients with MI.

[Prognostic value of exercise angioscintigraphy in coronary disease]

Multivariate survival analysis (MSA) was applied to 97 patients with coronary disease using the Cox model and a stepwise regression procedure. Seventeen variables including data based upon clinical examination, exercise testing (ET), and exercise angioscintigraphy (EAS) as well as coronary arteriography were studied in each patient. During the monitoring period (interval: 1-57 months), 38 patients sustained a cardiac event (recurrence of coronary disease or death). Neither resting left ventricular ejection fraction, nor coronary anatomy were significant prognostic variables. The only two variables identified by MSA were a variable of EAS: corrected ejection fraction at maximum exercise (p less than 0.008), and a variable of ET: maximum heart rate during exercise (p less than 0.03). This study shows that the prognosis of a coronary disease patient can best be assessed by two variables which are both exercise parameters.

[Malignant histiocytofibroma of the heart simulating myxoma of the left atrium]

The authors report a case of malignant fibrous histiocytoma of the left atrium which was excised but rapidly recurred in a 47-year-old woman. Clinical examination, echocardiography and the absence of biochemical abnormalities were in favour of the diagnosis of left atrial myxoma. This report illustrates the clinical similarity between myxoma and sarcoma of the left atrium. Very careful anatomopathological examination of multiple sections of the tumour are necessary to distinguish it from benign tumours, especially myxomas.

[Natural course of type III traumatic chronic dissection in a patient with Marfan's syndrome]

Description of a traumatic dissection of the descending thoracic aorta, occurring in a female patient with Marfan's syndrome, the chronic course of which over more than three years was complicated by retrograde extension to the ascending thoracic aorta, resulting in death by massive aortic insufficiency and pleuro-pericardial effusion. Advantages of clinical and sonocardiographic monitoring of chronic dissections.

[Role of clinical manifestations, the exercise test and exertion angioscintigraphy in the diagnosis of coronary disease. A multivariate study]

Data of clinical examination, exercise electrocardiography and stress radionuclide angiography in 102 patients referred for assessment of chest pain was included in a logistic regression to optimise the diagnosis of coronary artery disease with coronary angiography as the reference investigation. None of the patients had other cardiac problems nor previous myocardial infarction. In the absence of symptoms exercise testing was continued until at least 80 p. 100 of the theoretical maximal heart rate was attained. Each patient was characterised by the value of the logistic function or probability of coronary artery disease. A threshold value corresponding to 80 p. 100 sensitivity was determined by the technique of ROC graphs. The significant variables were: a clinical variable--the type of chest pain as assessed by the clinical history; two radionuclide angiographic variables--the ejection fraction at peak effort and the corrected variation of ejection fraction between rest and stress, that is not taking into account possible decreases at the last increment of exercise. Coronary patients can be identified with an 80 p. 100 sensitivity and 77 p. 100 specificity on these criteria. This specificity is greater than that obtained by clinical examination and exercise electrocardiography alone (65 p. 100). Stress radionuclide angiography may therefore reduce the number of unnecessary coronary angiographies.

[Floating thrombus of the right atrium in acute pulmonary embolism. Clinical, echocardiographic aspects and therapeutic sequelae]

The performance of a systematic sonocardiography in all our patients hospitalized since January 1985 for pulmonary embolism, has enabled to discover five cases of floating thrombus of the right atrium. Three patients presented an abnormal auscultation, with one of them presenting a tricuspid wedge syndrome. On the sonogram, the aspect of the thrombus, "coil or ball-shaped", floating in the atrial cavity, sometimes prolapsed through the tricuspid valve, associated with the signs of a pulmonary heart, enables to rule out other right intraatrial masses. Pulmonary angiography seems contra-indicated because of the risk of embolus of this thrombus, the migration of which may be fatal. Embolectomy, under extra-corporeal circulation (heart-lung pump) with examination of the right cavities appears to be the treatment of choice.

[Quantification of chronic aortic insufficiency. Comparison between Doppler ultrasonic diagnosis and the radiocardiogram]

The objective of this study is to quantify aortic insufficiency by comparing pulsated Doppler ultrasonography and radiocardiography used as reference test. Since february 1986, 23 patients were tested with both techniques within 15 days. The Doppler ultrasonography enabled to quantify aortic insufficiency in 4 stages by semi-quantitative mapping of the regurgitation flow of the left ventricle (LV). Radiocardiography (RCG) has enabled the determination of the regurgitation fraction (RF), for each patient. A mean RF was calculated on RCG, for each Doppler stage. The FR difference between each Doppler stage is significant, especially between minimal and severe aortic insufficiency. RCG is the first stage of an isotopic examination, at rest and during stress; it may be followed by Doppler ultrasonography in monitoring patients with aortic insufficiency.

Diagnostic value of stress radionuclide angiography in coronary artery disease: a comparison of different interpretation criteria

In order to compare different criteria in the interpretation of stress radionuclide angiography (SRNA) 96 patients with suspected coronary artery disease (CAD) were investigated by both SRNA and coronary arteriography. The result of coronary arteriography was taken as the gold standard for the diagnosis of CAD. Left ventricular ejection fraction (LVEF) was measured at each step of the stress study using the equilibrium radionuclide technique. The diagnostic value of eight interpretation criteria based on the evolution of global LVEF during stress were compared with each other, using the ROC technique. The best diagnostic criterion proved to be the normalized increase of LVEF proposed by Goris. The most commonly used criteria, LVEF increase and LVEF measured at maximal exercise, were not optimal. In the whole population of patients, the best criterion had a sensitivity of 85% for a specificity of 80% and a specificity of 83% for a sensitivity of 80%. In the population, following exclusion of patients with preceding myocardial infarction, the specificity was 74% for a sensitivity of 80% and a sensitivity of 74% for a specificity of 80%. Thus, the choice of interpretation criteria is very important in order to optimize the sensitivity and specificity of this diagnostic test.